Publications by authors named "Ulrich Kneser"

293 Publications

Thermo-mechanical combination injuries - A rare but life-threatening entity.

J Burn Care Res 2021 Sep 19. Epub 2021 Sep 19.

Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University Heidelberg, Ludwigshafen/Rhine, Germany.

Thermo-mechanical-combination-injuries (TMCI) are feared for their demanding preclinical and clinical management and bear the risk of high mortality compared to the single injury of a severe burn or multiple traumata. There remains a significant lack of standardized algorithms for diagnostics, and therapy of this rare entity. The aim of the present study was to profile TMCI aiming at standardized procedures. In this study, TMCI were extracted from our burn database of a level 1 burn and trauma centre. From 2004 to 2017, all patients with TMCI were retrospectively analyzed. Further inclusion criteria were multiple trauma accompanied by burn with ≥10% TBSA. Patient and injury characteristics including ISS and outcome parameter were analyzed. A total of 45 patients matched the selective inclusion criteria of TMCI comprising of 4% of all burn injuries during the period. Average age was 38 years (range: 14-86), with a mean TBSA of 43% (range: 10-97%). The mean recorded temperature at admission was 34.8°C (range: 29.6 - 37.1) with 2215 ml volume (range: 500 - 8000) administered preclinically in total. The mean ISS was 16. The overall mortality rate was 22%. TMCI are rare and life-threatening events which require highly qualified management in combined level 1 trauma and burn centres to adress both burn and trauma treatment. The multiple injury pattern is diverse, complicating standardized management in view of burn care specific measures, as normothermia and restrictive volume management. The present study reveals further profiles and underlines the need for addressing TMCI in ABLS®; ATLS® and PHTLS® programs.
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http://dx.doi.org/10.1093/jbcr/irab176DOI Listing
September 2021

Intra- and Extrathoracic Malignant Tracheoesophageal Fistula-A Differentiated Reconstructive Algorithm.

Cancers (Basel) 2021 Aug 27;13(17). Epub 2021 Aug 27.

Department of General, Vascular and Thoracic Surgery, RoMed Klinikum, 83022 Rosenheim, Germany.

Background: Tracheoesophageal fistulae (TEF) after oncologic resections and multimodal treatment are life-threatening and surgically challenging. Radiation and prior procedures hamper wound healing and lead to high complication rates. We present an interdisciplinary algorithm for the treatment of TEF derived from the therapy of consecutive patients.

Patients And Methods: 18 patients (3 females, 15 males) treated for TEF from January 2015 to July 2017 were included. Two patients were treated palliatively, whereas reconstructions were attempted in 16 cases undergoing 24 procedures. Discontinuity resection and secondary gastric pull-up were performed in two patients. Pedicled reconstructions were pectoralis major ( = 2), sternocleidomastoid muscle ( = 2), latissimus dorsi ( = 1) or intercostal muscle (ICM, = 7) flaps. Free flaps were anterolateral thigh (ALT, = 4), combined anterolateral thigh/anteromedial thigh (ALT/AMT, = 1), jejunum ( = 3) or combined ALT-jejunum flaps ( = 2).

Results: Regarding all 18 patients, 11 of 16 reconstructive attempts were primarily successful (61%), whereas long-term success after multiple procedures was possible in 83% ( = 15). The 30-day survival was 89%. Derived from the experience, patients were divided into three subgroups (extrathoracic, cervicothoracic, intrathroracic TEF) and a treatment algorithm was developed. Primary reconstructions for extra- and cervicothoracic TEF were pedicled flaps, whereas free flaps were used in recurrent or persistent cases. Pedicled ICM flaps were mostly used for intrathoracic TEF.

Conclusion: TEF after multimodal tumor treatment require concerted interdisciplinary efforts for successful reconstruction. We describe a differentiated reconstructive approach including multiple reconstructive techniques from pedicled to chimeric ALT/jejunum flaps. Hereby, successful reconstructions are mostly possible. However, disease and patient-specific morbidity has to be anticipated and requires further interdisciplinary management.
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http://dx.doi.org/10.3390/cancers13174329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8430587PMC
August 2021

A meta-analysis evaluating risk factors for compound free flaps for upper extremity defect reconstruction comparing complications and functional outcomes of compound free flaps with and without bone components.

Microsurgery 2021 Aug 6. Epub 2021 Aug 6.

Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.

Background: Compound flaps offer the advantage of one stage defect reconstruction respecting all relevant tissues and early functional recovery by optimal vascularity of all components. Due to its specific vascular anatomy and the three-dimensional donor site, compound flaps with bone components may result in higher complication rates compared to soft tissue compound flaps. The meta-analysis summarizes the available evidence and evaluates whether bone components are a risk factor for periprocedural complications in upper extremity multidimensional defect reconstruction.

Method: PubMed and Embase were searched for all publications addressing compound free flaps for upper extremity defect reconstruction with bone or soft tissue components published between January 1988 and May 2018. The methodological quality was assessed with the American Society of Plastic Surgeons Evidence Rating Scale for Therapeutic Studies. Flap loss, thrombosis rate, early infection, hematoma, seroma, as well as donor site complications were extracted and analyzed.

Results: Twelve out of 1157 potentially eligible studies (evidence-III) comprising 159 patients were finally included with publication bias for all summarized complication rates. Complication rates for flaps with/ without bone components were: total flap loss 5%, 95% CI = 3%-10% (6%/5%); partial flap loss 8%, 95% CI = 5%-15%, (9%/8%); arterial/venous thrombosis 7%, 95% CI = 4%-12%, (8%/5%)/14%, 95% CI = 9%-21% (16%/6%, P < .05) with higher risk for flaps with bone components; infection 6%, 95% CI = 3%-12% (6%/6%); hematoma 6%, 95% CI = 3%-11% (6%/5%); seroma 5%, 95% CI = 3%-10% (5%/5%); dehiscence 10%, 95% CI = 6%-17% (11%/9%).

Conclusion: Compound flaps for upper extremity defect reconstruction including bone components have a higher venous thrombosis rate compared to compound soft-tissue flaps.
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http://dx.doi.org/10.1002/micr.30791DOI Listing
August 2021

Implementation and Validation of Free Flaps in Acute and Reconstructive Burn Care.

Medicina (Kaunas) 2021 Jul 16;57(7). Epub 2021 Jul 16.

Department of Hand, Plastic and Reconstructive Surgery, Microsurgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, University Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany.

Microsurgical free flap reconstruction in acute burn care offers the option of reconstructing even challenging defects in a single stage procedure. Due to altered rheological and hemodynamic conditions in severely burned patients, it bears the risk of a higher complication rate compared to microsurgical reconstruction in other patients. To avoid failure, appropriate indications for free flap reconstruction should be reviewed thoroughly. Several aspects concerning timing of the procedure, individual flap choice, selection and preparation of the recipient vessels, and perioperative measures must be considered. Respecting these specific conditions, a low complication rate, comparable to those seen in microsurgical reconstruction of other traumatic limb defects, can be observed. Hence, the free flap procedure in acute burn care is a relatively safe and reliable tool in the armamentarium of acute burn surgery. In reconstructive burn care, microsurgical tissue transfer is routinely used to treat scar contractures. Due to the more robust perioperative condition of patients, even lower rates of complication are seen in microsurgical reconstruction.
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http://dx.doi.org/10.3390/medicina57070718DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8306341PMC
July 2021

Lymphovenous anastomoses with three-dimensional digital hybrid visualization: improving ergonomics for supermicrosurgery in lymphedema.

Arch Plast Surg 2021 Jul 15;48(4):427-432. Epub 2021 Jul 15.

Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen am Rhein, Germany.

The conventional approach of looking down a microscope to perform microsurgical procedures is associated with occupational injuries, anti-ergonomic postures, and increased tremor and fatigue, all of which predispose microsurgeons to early retirement. Recently, three-dimensional (3D) visualization of real-time microscope magnification has been developed as an alternative. Despite its commercial availability, no supermicrosurgical procedures have been reported using this technology to date. Lymphovenous anastomoses (LVAs) often require suturing vessels with diameters of 0.2-0.8 mm, thus representing the ultimate microsurgical challenge. After performing the first documented LVA procedure using 3D-augmented visualization in our unit and gaining experience with this technique, we conducted an anonymized in-house survey among microsurgeons who had used this approach. The participants considered that 3D visualization for supermicrosurgery was equivalent in terms of handling, optical detail, depth resolution, and safety to conventional binocular magnification. This survey revealed that team communication, resident education, and ergonomics were superior using 3D digital hybrid visualization. Postoperative muscle fatigue, tremor, and pain were also reduced. The major drawbacks of the 3D visualization microscopic systems are the associated costs, required space, and difficulty of visualizing the lymphatic contrast used.
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http://dx.doi.org/10.5999/aps.2020.01949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8342244PMC
July 2021

The status quo of early burn wound excision: Insights from the German burn registry.

Burns 2021 Sep 10;47(6):1259-1264. Epub 2021 Jul 10.

Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany. Electronic address:

Background: There is a common, well-known and established recommendation to excise burn wounds within 24-72 h in order to mitigate the systemic inflammatory and immunomodulatory response, shorten length of hospitalization through early grafting and optimize patient survival. Despite this apparent consensus, surprisingly few systematic studies have evaluated the actual adherence to this practice and its implications on patient outcomes. In this registry study, we sought to objectify the current status of early burn wound excision, its influencing factors and impact on patient outcomes for all German burn centers.

Methods: The German burn registry ('Deutsches Verbrennungsregister') was queried for 3 consecutive years for all patients, who received at least one surgical intervention. Patients were stratified based on whether the first surgical procedure was performed early (EE, within 72 h) or late (LE, after 72 h) post-burn. Descriptive statistics and univariate regressions were performed to quantify fraction of EE vs. LE and to evaluate factors which might favor one over the other (i.e. age, inhalation injury, burn severity by total body surface area (TBSA), scald vs. other burns, obesity, time of admission). Key patient outcomes were analyzed for each group (i.e. mortality, length of hospitalization, number of surgeries) and multifactorial regression analyses were carried out to model the impact of EE on mortality. Statistical significance was accepted at p < 0.05.

Results: After initial screening, 1494 complete records were included for final analysis and were stratified into EE and LE. Only 670 (44%) underwent EE within 72 h. Increasing TBSA burned (i.e. [TBSA > 30%]: 53.8% EE, [TBSA < 30%]: 43.5% EE, p < 0.01) and admission on a weekday between Sunday and Wednesday were associated with higher probability of EE (51.5% EE) versus Thursday to Sunday (37.3%, p < 0.001). Age, inhalation injury, cause of burn, and obesity had no effect on EE vs. LE. Patients with EE had significantly shorter median lengths of hospitalization (EE: 18 d, LE: 21 d, p < 0.01). The median number of operations was comparable for both groups. Gross mortality appeared higher in the EE group, but turned out to be comparable to LE after correction for age, TBSA and sex in multifactorial regression analysis.

Conclusion: Despite apparent consensus among burn physicians, early excision of burn wounds is performed in less than 50% of cases in German burn centers. The relationship of EE to TBSA burned is expected and clinically sound, while a dependence on admission weekday raises administrative and infrastructural questions, especially when patients who receive EE have significantly shorter hospital stays. More analyses from other burn repositories are needed to compare and benchmark the international status quo of early burn wound excision.
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http://dx.doi.org/10.1016/j.burns.2021.06.010DOI Listing
September 2021

What We Really can Learn From Aviation: Checklist-based Team Time-Out in Conjunction With Interpersonal Competence Training for the Daily Management of a Surgical Department.

Surg Innov 2021 Oct 28;28(5):642-646. Epub 2021 Jul 28.

Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation-Centre, 72067Unfallklinik Frankfurt/Main gGmbH, Academic Teaching Hospital of Goethe-University of Frankfurt, Ludwigshafen, Germany.

Aviation and affiliated training concepts have gained a pioneering role in the establishment of interpersonal competence training for physicians and in particular for surgical disciplines. Strengthening interpersonal competence in conjunction with standardized processes and tools aims at implementing safety and error culture in the clinical surroundings while improving patient safety. In a surgical center, safety culture starts with decisive day-to-day management, continues with WHO team time-out and optimal surroundings for the operation, and goes beyond mortality and morbidity conferences and reevaluation of the daily work. Nevertheless, operational day-to-day management has been only little in the focus of security and error culture in surgical literature yet. Interpersonal competence training has been introduced in the hospital group. In 2017, a checklist-based team time-out was implemented to optimize day-to-day management so that conflicts and collisions can be identified timely. The daily completed checklist addresses changes in staff and resource availability, patient-relevant, and other organizational factors. The introduction has provided a significant level of stability and proven itself as part of the safety culture and exemplary leadership beyond the "classical" fields in surgery. This "simple" instrument from the aviation toolbox in conjunction with interpersonal competence training can be recommended to improve the management and safety culture in a surgical clinic to streamline operations and positively affect patient safety and staff development as well as employee satisfaction. Nevertheless, it is not sufficient to implement standard operation procedures templates and checklists, and they have to be lived daily and by everyone.
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http://dx.doi.org/10.1177/15533506211018439DOI Listing
October 2021

Expression of Connexin43 Stimulates Endothelial Angiogenesis Independently of Gap Junctional Communication In Vitro.

Int J Mol Sci 2021 Jul 9;22(14). Epub 2021 Jul 9.

Institut für Physiologie, Universität zu Lübeck, 23562 Lübeck, Germany.

Connexins (Cx) form gap junctions (GJ) and allow for intercellular communication. However, these proteins also modulate gene expression, growth, and cell migration. The downregulation of Cx43 impairs endothelial cell migration and angiogenetic potential. Conversely, endothelial Cx43 expression is upregulated in an in vivo angiogenesis model relying on hemodynamic forces. We studied the effects of Cx43 expression on tube formation and proliferation in HUVECs and examined its dependency on GJ communication. Expectedly, intercellular communication assessed by dye transfer was linked to Cx43 expression levels in HUVECs and was sensitive to a GJ blockade by the Cx43 mimetic peptide Gap27. The proliferation of HUVECs was not affected by Cx43 overexpression using Cx43 cDNA transfection, siRNA-mediated knockdown of Cx43, or the inhibition of GJ compared to the controls (transfection of an empty vector, scrambled siRNA, and the solvent). In contrast, endothelial tube and sprout formation in HUVECs was minimized after Cx43 knockdown and significantly enhanced after Cx43 overexpression. This was not affected by a GJ blockade (Gap27). We conclude that Cx43 expression positively modulates the angiogenic potential of endothelial cells independent of GJ communication. Since proliferation remained unaffected, we suggest that Cx43 protein may modulate endothelial cell migration, thereby supporting angiogenesis. The modulation of Cx43 expression may represent an exploitable principle for angiogenesis induction in clinical therapy.
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http://dx.doi.org/10.3390/ijms22147400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8306600PMC
July 2021

Functional and aesthetic reconstruction of a dorsal digital skin defect with a sensory neurotized DMCA III flap.

Case Reports Plast Surg Hand Surg 2021 6;8(1):102-104. Epub 2021 Jul 6.

Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Heidelberg, Germany.

The dorsal metacarpal artery (DMCA) flap is an elegant way to reconstruct tissue defects. We present a 25-year-old female patient with a dorsal injury on the fourth digit, which was reconstructed with a third webspace DMCA flap which was neurorrhaphied with a branch of the ulnar nerve, to regain sensation.
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http://dx.doi.org/10.1080/23320885.2021.1942879DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8266252PMC
July 2021

The impact of closed incisional negative pressure therapy on anterior lateral thigh flap donor site healing and scarring: A retrospective case-control study.

J Plast Reconstr Aesthet Surg 2021 Jun 13. Epub 2021 Jun 13.

Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany; Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany. Electronic address:

Background: The objective of this study was to investigate whether closed incisional negative pressure therapy (cINPT) is suitable to improve anterior lateral thigh (ALT) flap donor site healing and scarring.

Methods: We identified 271 ALT free flaps of widths between 7 and 9 cm and primary donor site closure performed between January 2012 to December 2019. Patients were divided into cases of cINPT versus controls without cINPT as part of this retrospective case-control review. We compared the incidences of postoperative donor site complications (wound dehiscence, infection, seroma, hematoma) and the degree of scarring severity using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS).

Results: A total of 106 ALT donor sites received cINPT (39%), whereas the remaining 165 donor sites received conventional dressings (61%). The distribution of gender, age, body mass index, comorbidities, and mean flap sizes were comparable between both groups. The occurrence of surgical wound dehiscence was significantly lower in the cINPT group (2.8%), when compared to controls (9.0%) (p = 0.04). Furthermore, the mean length of postoperative hospital stay was significantly shorter in the cINPT group (19 ± 8 days versus 21 ± 11 days; p = 0.03). CINPT was associated with a more favorable donor site scar quality when assessed by VSS (p = 0.03) and POSAS (p = 0.002).

Conclusion: The use of cINPT was associated with significantly less ALT donor site complications and superior scar quality accelerating patients' postoperative recovery.
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http://dx.doi.org/10.1016/j.bjps.2021.05.049DOI Listing
June 2021

Single incision thenar muscle reconstruction using the free functional pronator quadratus flap.

BMC Surg 2021 Jul 12;21(1):310. Epub 2021 Jul 12.

Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.

Background: Injuries to the thenar muscle mass or the thenar branch of the median nerve and resulting loss of thumb opposition lead to a massive impairment of hand function. For decades, reconstructive approaches were based on tendon transfers. To broaden the reconstructive repertoire, we present the free functional pronator quadratus flap as a viable alternative for functional reconstruction and provide a specification for its indication. We demonstrate our surgical technique to a single incision reconstruction using the free functional pronator quadratus flap. Based on a series of three patients, which were analyzed for hand function using Kapandji's score and the angle of Bourrel, grip strength and nerve conduction velocity in a two year follow up, we present an indication algorithm.

Results: After successful reinnervation of all flaps, we found an improvement of Kapandji's score from 4.3 ± 0.94 preoperatively, to 8.7 ± 0.47 after two years. Accordingly, the angle of Bourrel decreased from 75.75 ± 3.45 degrees to 36.96 ± 3.68 degree. Grip strength also improved from 14 ± 2.2 kg to 26.2 ± 1.2 kg. No impairment of wrist pronation was observed.

Conclusion: We found excellent functional recovery of thumb opposition and strength, showing similar or even superior results compared to results from tendon transfers. With the benefit of a single incision surgery and therefore minimal donor site morbidity, this free functional muscle transfer is a viable alternative to classic tendon transfers.
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http://dx.doi.org/10.1186/s12893-021-01308-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276497PMC
July 2021

Long-term sequelae of critical illness in sepsis, trauma and burns: a systematic review and meta-analysis.

J Trauma Acute Care Surg 2021 Jul 9. Epub 2021 Jul 9.

Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA Division of Molecular and Translational Cardiology, Department of Internal Medicine III University Hospital Heidelberg, Germany.

Background: Sepsis, major trauma and severe burn injury are life-threatening critical illnesses that remain significant contributors to worldwide morbidity and mortality. The three underlying etiologies share pathophysiological similarities: hyperinflammation, hypermetabolism, and acute immunomodulation. The aim of this study is to assess the current state of long-term outcome research, and to identify key outcome parameters between the three forms of critical illness.

Methods: This systematic review (SR) and meta-analysis (MA) were conducted according to the PRISMA guidelines. PubMed was searched from January 1st, 1975 to December 31st, 2019. Studies were assessed for eligibility by independent reviewers. Inclusion criteria were studies reporting at least a 6-month follow-up of health-related quality of life (HRQoL), and organspecific sequelae within the three etiologies: severe burn injury, sepsis, and major trauma.

Results: In total 125 articles could be included in the SR and 74 in the MA. The mean follow-up time was significantly longer in burn studies, compared to sepsis and trauma studies. The majority of patients were from the sepsis group, followed by burns, and major trauma studies. In the overall HRQoL, as assessed by ShortForm-36, and European Quality-of-Life Index, the three different etiologies were comparable to one another.

Conclusion: The effects of critical illness on survivors persist for years after hospitalization. Well-reported and reliable data on the long-term outcomes are imperative, as they can be used to determine the treatment choice of physicians as well as to guide the expectations of patients, improving the overall quality of care of three significant patient cohorts.

Level Of Evidence: III.
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http://dx.doi.org/10.1097/TA.0000000000003349DOI Listing
July 2021

A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times.

Microsurgery 2021 Jun 24. Epub 2021 Jun 24.

Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany.

Introduction: We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety.

Methods: 150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated.

Results: Cases and controls were comparable regarding age (p = .48), sex (p = .81), ASA class (p = .48), and BMI (p = .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10 min, p < .0001) and operative times (74 ± 16 min, p < .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p < .0001). Additionally, while there was no effect on the emergency take-back rate (OR = 1.3, p = .60), revisions were significantly less likely among duplexed patients (OR = 0.15, p = .04).

Conclusions: Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.
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http://dx.doi.org/10.1002/micr.30775DOI Listing
June 2021

Safety and donor site morbidity of the transverse musculocutaneous gracilis (TMG) flap in autologous breast reconstruction-A systematic review and meta-analysis.

J Surg Oncol 2021 Sep 6;124(4):492-509. Epub 2021 Jun 6.

Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany.

Background And Objectives: The transverse musculocutaneous gracilis (TMG) flap has gained popularity for breast reconstruction. However, the literature regarding its donor site morbidity is heterogeneous. This systematic review sought to clarify the evidence on donor site morbidity.

Methods: A systematic literature search was conducted. We included all articles reporting on donor-site morbidity of the TMG flap for breast reconstruction. The results were analyzed in R and its extension meta. A generalized linear mixed model was used to combine proportions and their 95% confidence intervals (CIs) in a random-effects meta-analysis.

Results: Nineteen articles provided an overall sample of 843 TMG flaps. The total flap loss was low at 2% (95% CI, 1%-3%). All patients were normal weight (pooled body mass index 22.75, 95% CI, 21.88-23.63). The incidence of wound dehiscence (8%, 95% CI, 4%-16%), seroma (4%, 95% CI, 2%-7%), hematoma (2%, 95% CI, 1%-4%) and infection (0%-5%) on the TMG donor site was low. Functional impairments included sensory disturbance (0%-74%), motoric deficits (0%-50%), and changes in the genital region (0%-24%), all of which were modest.

Conclusions: This review confirms the safety and low donor site morbidity of the TMG flap in normal-weight patients, which is comparable to that of other popular free flaps in breast reconstruction.
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http://dx.doi.org/10.1002/jso.26559DOI Listing
September 2021

The transverse musculocutaneous gracilis flap for autologous breast reconstruction: focus on donor site morbidity.

Breast Cancer 2021 Jun 6. Epub 2021 Jun 6.

Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany.

Purpose: The transverse musculocutaneous gracilis (TMG) flap is as a valuable alternative in autologous breast reconstruction. The purpose of this study was to evaluate the donor site morbidity and secondary refinement procedures after TMG flap breast reconstruction.

Methods: A retrospective study was conducted, including all patients who received TMG flap breast reconstructions, from January 2012 to August 2019. Primary outcomes were surgical site complications of the donor site and secondary refinement procedures carried out for aesthetic or reconstructive purposes for the medial thigh. Secondary outcomes of interest were lipofilling procedures for optimization of the reconstructed breasts.

Results: Ninety-nine patients received 159 TMG flaps for breast reconstruction. Patients' mean BMI was 23.5 (15.6-32.5) kg/m. Bilateral breast reconstructions were performed in 60.6%. The mean flap volume was 330 (231-440) g. Surgical site complications occurred in 14.5% of the TMG donor sites and wound dehiscence was the most common complication (9.4%). Lymphedema occurred in 1.8% of the donor thighs. Aesthetic refinement procedures were performed in 25.2% on the donor thigh or contralateral thigh. Secondary lipofilling was performed in 54.1% of the reconstructed breasts and fat was harvested in only 11.9% from the legs.

Conclusion: The TMG flap breast reconstruction combines low donor site morbidity with adequate volume for appealing breast results, particularly in slim-to-normal weight patients. However, patients should be informed about the likelihood of secondary refinement procedures on the donor site and the need of lipofilling to optimize the breast shape and volume.
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http://dx.doi.org/10.1007/s12282-021-01264-7DOI Listing
June 2021

A Retrospective Comparative Functional and Aesthetic Outcome Study of Muscle versus Cutaneous Free Flaps for Distal Upper Extremity Reconstruction.

J Reconstr Microsurg 2021 May 19. Epub 2021 May 19.

Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany.

Background:  Function and cosmesis are crucial in upper extremity reconstruction. Yet, there persists a lack of outcome evaluations, particularly regarding differences between free flap types.

Methods:  In a single-center retrospective analysis, outcomes were compared between patients with cutaneous or muscle free flaps for distal upper extremity reconstruction between 2008 and 2018. The Disabilities of Arm, Shoulder and Hand -Score, Michigan-Hand (MHQ), and Short Form 36 Health Survey (SF-36) Questionnaires were assessed, motor function was quantified, and self-reported measures of cosmesis were compared, including the Vancouver Scar-Scale (VSS), MHQ aesthetics-subscale (MAS), and Moscona's cosmetic validation-score (CVS).

Results:  One-hundred forty-one cases were identified, with a shift toward cutaneous flaps over the study period. Muscle flaps were used for larger defects (251 vs. 142 cm,  = 0.008). Losses, thromboses, and donor-site complications were equally distributed. Partial necroses were more frequent in muscle flaps (11 vs. 1%,  = 0.015). Seventy patients with 53 cutaneous versus 17 muscle flaps were reexamined. There was no difference in the timing of flap coverage (after 16 vs. 15 days,  = 0.79), number of preceding (2 vs. 1.7,  = 0.95), or subsequent operations (19/53 vs. 5/17,  = 0.77). Patients with cutaneous flaps showed higher grip strength (25 vs. 17 kg,  = 0.046) and reported better hand function (MHQ: 58 vs. 47,  = 0.044) and general health (SF-36: 70 vs. 61,  = 0.040), as well as more favorable appearance (MAS: 71 vs. 57,  = 0.044, CVS: 77 vs. 72,  = 0.048), and scar burden (VSS: 0 vs. 3,  < 0.001).

Conclusion:  Cutaneous flaps yielded better motor function, self-perceived cosmesis, patient satisfaction, and quality of life in our cohort of distal upper extremity reconstructions.
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http://dx.doi.org/10.1055/s-0041-1729882DOI Listing
May 2021

[The free serratus carpaccio flap: indications and technique].

Handchir Mikrochir Plast Chir 2021 May 19. Epub 2021 May 19.

Klinikum Sankt Georg, Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum, Leipzig.

Purpose: Soft tissue reconstructions of the hand require a thin and resistant flap palmarly as well as sliding abilities between the extensor tendons and the flap on the dorsum of the hand. Elasticity is required to maintain the normal wrist range of motion. One option in these cases is the free serratus fascia flap that sometimes shows limitations regarding resistance as well as reliability. Here, we describe an easy modification including a thin muscle cuff in the serratus fascia flap - the serratus carpaccio flap - that improves the ease of flap harvest and morbidity rates.

Methods: The indications for the serratus carpaccio flap, the technique of flap harvest and contouring as well as flap inset are described in detail. Clinical examples are given.

Results: The main advantage of the serratus carpaccio flap is the ability of the surgeon to adapt the flap thickness to the recipient site requirements. This allows excellent results regarding contour and function. Split thickness skin grafting fromthe instep region of the foot additionally allows optimal results for palmar as well as plantar defect reconstruction. Eighteen flaps for soft tissue defects of the hand (n = 5), foot (n = 10), and lower leg (n = 3) were performed. Complications included one flap loss, one venous re-anastomosis, two partial wound dehiscences and one postoperative hematoma at the donor site. Seventeen flaps survived completely. Secondary thinning procedures were not required.

Conclusions: The serratus carpaccio flap is an excellent option for the reconstruction of medium-sized skin and soft tissue defects of the dorsum of the hand or foot, the palm, and the distal forearm.
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http://dx.doi.org/10.1055/a-1439-9873DOI Listing
May 2021

[Deep sternal wound infection after sternotomy - Report of the consensus workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM)].

Handchir Mikrochir Plast Chir 2021 May 5. Epub 2021 May 5.

Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Medizinische Universität Innsbruck, Österreich.

Deep sternal wound infection (TSWI) is a potentially life-threatening complication that may occur after median sternotomy, contributing to prolonged hospital stay and increased health care costs. Bacterial infection is often characterized by biofilm formation on implant material and/or dead bone. Diagnosis is made upon clinical signs and symptoms of local and systemic infection. Early multidisciplinary decision making is needed for optimal patient care. Repeated surgical wound debridements accompanied by wound conditioning are performed until clean circumstances are achieved. Thereafter, wound closure and defect reconstruction are obtained using a variety of pedicled and microvascular flaps.
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http://dx.doi.org/10.1055/a-1425-5987DOI Listing
May 2021

Utilization of Interdisciplinary Tumor Boards for Sarcoma Care in Germany: Results from the PROSa Study.

Oncol Res Treat 2021 22;44(6):301-312. Epub 2021 Apr 22.

Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany.

Background: Data on institutional structures of sarcoma care in Germany are scarce. The utilization of an interdisciplinary tumor board (IDTB) is an essential part of modern cancer care. We investigated to which extent and when IDTB are used in sarcoma care. We hypothesized that IDTB before treatment initiation were used more often at certified cancer centers and at high-volume centers and that IDTB utilization increased over time.

Methods: From 2017 to 2020 we conducted a prospective cohort study, undertaking major efforts to include the whole spectrum of sarcoma treatment facilities. To analyze potential predictors of IDTB utilization, we calculated multivariable logistic regressions.

Results: Patients and survivors (n = 1,309) from 39 study centers (22 tertiary referral hospitals, 9 other hospitals, and 8 office-based practices) participated; 88.3% of the patients were discussed at some stage of their disease in an IDTB (56.1% before treatment, 78% after therapy, and 85.9% in metastatic disease). Hypotheses were confirmed regarding the utilization of IDTB in certified cancer centers (vs. all others: OR = 5.39; 95% CI 3.28-8.85) and the time of diagnosis (2018/2019 vs. until 2013: OR = 4.95; 95% CI 2.67-9.21).

Conclusion: Our study adds to the evidence regarding the institutional structures of sarcoma care in Germany. Utilization of a tumor board before therapy seems to be in an implementation process that is making progress but is far from complete. Certification is a possible tool to accelerate this development.
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http://dx.doi.org/10.1159/000516262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8220922PMC
September 2021

[Evaluation of secondary refinement procedures following free microvascular tissue reconstruction of the upper extremity].

Handchir Mikrochir Plast Chir 2021 Aug 13;53(4):356-363. Epub 2021 Apr 13.

BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg.

Background:  The primary cosmetic and functional outcome following successful upper limb salvage using free tissue transfer can often be unfavourable, which may motivate patients to undergo secondary procedures. In this study, we sought to identify predictors for secondary procedures and to analyse the type and number of these procedures.

Patients And Methods:  Patients who underwent free tissue transfer to the upper extremity between 2010 and 2017 were included in a retrospective cohort study: patients with secondary procedures to optimise the functional and aesthetic flap design (S cohort) vs. control cohort (C cohort). A multivariate regression analysis was used to identify predictors for secondary procedures.

Results:  One hundred and twenty-eight patients were included in the study (S cohort 36, C cohort 92). All in all, 56 secondary refinement procedures were performed in a mean of eight months after the initial free flap reconstruction. Most of the defects in the S cohort were localised at the hand (53 %), and upper limb salvage was mostly accomplished by fasciocutaneous and adipocutaneous free flaps (S cohort 89 %). The most frequently performed secondary refinement procedures were direct partial flap excision (61 %), followed by liposuction (16 %) and the combination of both (17 %). Furthermore, 64 % of the secondary refinement procedures from the S cohort were combined with further surgical interventions to improve hand function, e. g. tenolysis and arthrolysis. Patients with defects of the hand received secondary procedures 2.4 times more frequently (p = 0.05). Also, patients with a good general health condition (ASA 1 and 2) were six times more likely to undergo a secondary procedure (p = 0.03).

Conclusion:  Secondary procedures are safe and frequently requested by patients following successful free flap upper limb salvage. In particular, this applies to patients who are in a good health condition and with free flaps to the hand. Therefore, we recommend the implementation of secondary refinement procedures in the reconstructive plan to increase patient compliance and satisfaction.
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http://dx.doi.org/10.1055/a-1294-9593DOI Listing
August 2021

Fibroadipose Vascular Anomaly of the Upper Extremity: Case Report of Extensive Resection and Secondary Tendon Transfer.

Ann Plast Surg 2021 Apr 5. Epub 2021 Apr 5.

From the Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg Institute for Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Mannheim Institute of Pathology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.

Abstract: Alomari and colleagues described in 2014 for the first time a distinct combination of vascular malformation, fibrofatty muscular infiltration and contracture which was termed fibroadipose vascular anomaly (FAVA) (J Pediatr Orthoped 34, 109 117 (2014). So far only few publications (J Pediatr Orthoped (2014) 34, 109 117; J Hand Surg (2020). 45, 68.e1, 68.e13; Ann Vasc Dis (2014) 7, 316-319; Pediatr Radiol 46, 1179-1186 (2016)) concerning this newly described disease have been published, covering only a limited number of cases. We present a case of a 19-year-old male patient suffering from a FAVA of the proximal forearm with a severe contracture of the infiltrated flexor musculature. Upon surgery, we observed infiltration of the ulnar nerve. We were able to successfully resect the vascular malformation. Secondary tendon transfer was performed after extensive resection of the flexor musculature.FAVA presents a differential diagnosis in patients with solid growth of the upper or lower extremity and contracture of the involved extremity. We conclude that patients suffering from FAVA of the upper extremity should be referred to a center specialized in oncologic extremity surgery and reconstructive hand and microsurgery.
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http://dx.doi.org/10.1097/SAP.0000000000002792DOI Listing
April 2021

Multidisciplinary team meetings for patients with complex extremity defects: a retrospective analysis of treatment recommendations and prognostic factors for non-implementation.

BMC Surg 2021 Mar 29;21(1):168. Epub 2021 Mar 29.

Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany.

Background: This study aimed to assess a multidisciplinary team (MDT) meeting approach for the management of patients with complex extremity defects, analyze treatment recommendations, and evaluate factors influencing non-implementation.

Methods: All patients introduced to an MDT meeting for complex extremity defects from 2015 to 2017 were included in a retrospective cohort study. Patients' characteristics and defect causes were evaluated. Treatment recommendations (TR) of MDT meetings and subsequent implementation were reviewed (cohort with implementation of TR versus cohort with non-implementation of TR), and factors associated with non-adherence to recommendations were statistically analyzed using logistic regression.

Results: Fifty-one patients (41 male) with a mean age of 54 years were presented in 27 MDT meetings. Most of the patients (70%) suffered from reconstructive challenging or combined bone- and soft tissue defects, primarily located at the lower extremity (88%). Large skeletal defects, chronic osteomyelitis, and multi-fragmented fractures were present in 65% of cases. Forty-five percent of the patients suffered from peripheral vascular disease, necessitating surgical optimization. Of the 51 MDT decisions, 40 were implemented (78%; (32/40) limb salvage versus 22%; (8/40) limb amputation). Limb salvage was successfully achieved in 91% (29/32) of the cases. Failed limb salvages were due to flap failure (33%; 1/3), recurring periprosthetic joint infections (66%; 2/3) and concomitant reconstructive failure. Patients who underwent limb amputation, as recommended, showed proper stump healing and regained mobility with a prosthesis. Overall the MDT treatment plan was effective in 92.5% (37/40) of the patients, who adhered to the MDT treatment recommendation. In eleven patients (22%; 11/51), the MDT treatment was not implemented. MDT decisions were less likely to be implemented, if amputation was recommended (p = 0.029).

Conclusions: MDT meetings represent a valid tool to formulate individualized treatment plans, avoiding limb amputation in most patients with severe extremity defects. Recommendation for limb amputation is less likely to be implemented than plans for limb salvage.

Trial Registration: Retrospectively registered.
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http://dx.doi.org/10.1186/s12893-021-01169-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006355PMC
March 2021

Comparison of pedicled versus free flaps for reconstruction of extensive deep sternal wound defects following cardiac surgery: A retrospective study.

Microsurgery 2021 May 29;41(4):309-318. Epub 2021 Mar 29.

Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany.

Background: Myocutaneous pedicled flaps are the method of choice for sternal reconstruction after deep sternal wound infection (DSWI) following cardiac surgery. We set out to investigate whether free flaps provide a superior alternative for particularly extended sternal defects.

Methods: Between October 2008 and February 2020, 86 patients with DSWI underwent sternal reconstruction with myocutaneous flaps at our institution. Patients were retrospectively grouped into pedicled (A; n = 42) and free flaps (B, n = 44). The objective was to compare operative details, outcome variables, surgical as well as medical complication rates between both groups, retrospectively. Binary logistic regression analysis was applied to determine the effect of increasing defect size on flap necrosis.

Results: Rates of partial flap necrosis (>5% of the skin island) were significant higher in pedicled flaps (n = 14), when compared to free flaps (n = 4) (OR: 5.0; 33 vs. 9%; p = .008). Increasing defect size was a significant risk factor for the incidence of partial flap necrosis of pedicled flaps (p = .012), resulting in a significant higher rate of additional surgeries (p = .036). Binary regression model revealed that the relative likelihood of pedicled flap necrosis increased by 2.7% with every extra square-centimeter of defect size.

Conclusion: To avoid an increased risk of partial flap necrosis, free flaps expand the limits of extensive sternal defect reconstruction with encouragingly low complication rates and proved to be a superior alternative to pedicled flaps in selected patients.
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http://dx.doi.org/10.1002/micr.30730DOI Listing
May 2021

Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures.

J Reconstr Microsurg 2021 Sep 16;37(7):608-616. Epub 2021 Feb 16.

Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.

Background:  Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures.

Methods:  A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed.

Results:  A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%;  = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 ( = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%;  = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%;  = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%;  = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss ( = 0.32 and  = 1.0).

Conclusion:  In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.
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http://dx.doi.org/10.1055/s-0041-1723823DOI Listing
September 2021

Lymphatic Tissue Engineering: A Further Step for Successful Lymphedema Treatment.

J Reconstr Microsurg 2021 Jul 31;37(6):465-474. Epub 2021 Jan 31.

Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany.

Background:  Secondary lymphedema, caused by oncologic surgery, radiation, and chemotherapy, is one of the most relevant, nononcological complications affecting cancer survivors. Severe functional deficits can result in impairing quality of life and a societal burden related to increased treatment costs. Often, conservative treatments are not sufficient to alleviate lymphedema or to prevent stage progression of the disease, as they do not address the underlying etiology that is the disruption of lymphatic pathways. In recent years, lymphatic surgery approaches were revolutionized by advances in microsurgical technique. Currently, lymphedema can effectively be treated by procedures such as lymphovenous anastomosis (LVA) and lymph node transfer (LNT). However, not all patients have suitable lymphatic vessels, and lymph node harvesting is associated with risks. In addition, some data have revealed nonresponders to the microsurgical techniques.

Methods:  A literature review was performed to evaluate the value of lymphatic tissue engineering for plastic surgeons and to give an overview of the achievements, challenges, and goals of the field.

Results:  While certain challenges exist, including cell harvesting, nutrient supply, biocompatibility, and hydrostatic properties, it is possible and desirable to engineer lymph nodes and lymphatic vessels. The path toward clinical translation is considered more complex for LNTs secondary to the complex microarchitecture and pending final mechanistic clarification, while LVA is more straight forward.

Conclusion:  Lymphatic tissue engineering has the potential to be the next step for microsurgical treatment of secondary lymphedema. Current and future researches are necessary to optimize this clinical paradigm shift for improved surgical treatment of lymphedema.
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http://dx.doi.org/10.1055/s-0040-1722760DOI Listing
July 2021

Safety of a Modified Lipoabdominoplasty Technique for Donor-Site Closure in Abdominal-Based Free Flap Breast Reconstruction.

Aesthetic Plast Surg 2021 08 22;45(4):1431-1440. Epub 2021 Jan 22.

Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.

Background: The aesthetic and functional outcomes of the donor site following abdominal-based free flap breast reconstruction have been suboptimal. The objective of this study is to evaluate a modified liposuction-assisted abdominoplasty technique combined with rectus plication (LPARSP) adopted from cosmetic abdominoplasty practice.

Patients And Methods: All abdominal-based free flap breast reconstructions from 01/2017 to 03/2019 were reviewed. Patients with central fullness and sufficient tissue surplus on the abdomen, thighs and flanks who received LPARSP and rectus plication were identified (LPARSP group) and matched for age and body mass index with patients who underwent conventional abdominoplasty (CA group). Abdominal skin sensation, objective functional and aesthetic measures of the abdomen, as well as patient-reported outcomes (Breast-Q), were analyzed.

Results: A total of 28 patients were included. Groups were similar in demographics. The mean amount of lipoaspirate in the LPARSP group was 1054±613.5 ml. The postoperative course was similar in both groups. The LPARSP technique resulted in a lower positioned horizontal scar (p = 0.03). The aesthetic outcome was superior in the LPARSP group (p < 0.0001). Furthermore, the LPARSP group presented with a decreased bulging rate (p = 0.05), and secondary refinement procedures were less frequently demanded (p = 0.02). In addition, the abdominal wall sensation of the flanks was improved in the LPARSP group (p = 0.05), whereby patient-reported outcome measures did not differ between groups.

Conclusions: Lipoabdominoplasty with rectus plication represents a safe approach for donor-site closure in selected patients undergoing abdominal-based free flap breast reconstruction. Superior functional and aesthetic results paired with improved abdominal wall sensation are achieved compared to CA.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-020-02117-yDOI Listing
August 2021

Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-A propensity score matching analysis in 5386 ACS-NSQIP patients.

J Plast Reconstr Aesthet Surg 2021 05 2;74(5):1031-1040. Epub 2020 Nov 2.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA. Electronic address:

Background: Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage.

Methods: By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort.

Results: We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001).

Conclusion: Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage.
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http://dx.doi.org/10.1016/j.bjps.2020.10.045DOI Listing
May 2021

[Immunosuppressive effect of mitomycin C-treated peripheral mononuclear blood cells (MICs) in vascularised composite allotransplantation].

Handchir Mikrochir Plast Chir 2021 Aug 7;53(4):389-399. Epub 2021 Jan 7.

BG Unfallklinik Ludwigshafen, Klinik f. Hand-, Plast. u. Rekonstr. Chirurgie, Schwerbrandverletztenzentrum.

Background: Vascularized Composite Allotransplantation (VCA) enables the restoration of complex tissue defects. Since the first successful hand and face transplants were performed, clinical and experimental research has consistently improved immunosuppressive therapies. The incubation of peripheral blood mononuclear cells (PBMCs) with mitomycin C (MMC) results in immunomodulatory cells (MICs). In previous studies, the systemic application of MICs on the day of allogeneic hind limb transplantation led to a significant immunosuppression in rats. The aim of this study is to further investigate the optimal point in time of MIC application in a complex VCA model.

Material And Methods: In six groups, 60 allogeneic hind limb transplantations were performed. Fully mismatched rats were used as hind limb donors [Lewis (LEW)] and recipients [Brown-Norway (BN)]. Group A received donor-derived MICs seven days preoperatively. Group B received no immunosuppression; group C received untreated PBMCs seven days prior to transplantation. Animals in group D received cell culture media, whereas group E was treated with a standard immunosuppression consisting of tacrolimus and prednisolone. In group F, syngeneic hind limb transplantations (BN→BN) were performed. Transplant rejection was assessed clinically and histologically.

Results: Group A showed a significantly earlier onset of allograft rejection after 3.5 ± 0.2 days (p < 0.01) when compared with control groups B, C and D (5.5 ± 0.7, 5.3 ± 0.7 und 5.7 ± 0.5). Groups E and F showedno allograft rejection.

Conclusion: This study shows that the time of application determines the immunomodulatory effects of MICs. Whereas the systemic application of MICs on the day of transplantation led to a significant immunosuppression in previous studies, this study demonstrates that preoperative injections of MICs lead to an acceleration of allotransplant rejection. Follow-up studies are necessary to investigate further modifications of application time as well as dose-effect relations and cell characteristics of these potential immunosuppressive cells.
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http://dx.doi.org/10.1055/a-1261-3447DOI Listing
August 2021

Enzymatic debridement for burn wound care: Interrater-reliability and impact of experience in post-intervention therapy decision.

J Burn Care Res 2020 Dec 30. Epub 2020 Dec 30.

BG Trauma Center Ludwigshafen, Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, Hand and Plastic Surgery of the University of Heidelberg, Germany.

Introduction: Enzymatic debridement (ED) has become a reliable tool for eschar removal. Although ED application is simple, wound bed evaluation and therapy decision post-intervention are prone to subjectivity and failure. Experience in ED might be the key, but this has not been proven yet. Aim of this study was to assess interrater reliability (IR) in post-intervention wound bed evaluation and therapy decision as well as the impact of experience. In addition, the authors introduce video assessment as a valuable tool for post-ED decision making and education.

Material And Methods: A video-based survey was conducted among physicians with various experience in ED. The survey involved multiple choice and 5-point Likert scale questions about professional status, experience in ED, confidence in post-ED wound bed evaluation and therapy decision. Subsequently, videos of 15 mixed pattern to full thickness burns immediately after removal of the enzyme complex were demonstrated. Participants were asked for evaluation of each burn wound, including bleeding pattern and consequent therapy decision. IR ≥80% was considered as a consensus. Responses were stratified according to participants' experience in applying ED (<10; 10-19; 20-49; ≥50 applications). IR was assessed by Chi^2-test (raw agreement (RA); ≥80% was considered as a consensus) and by Krippendorff's Alpha-test. In addition, expert consensus for therapy decision was compared to the actual clinical course of each shown patient. Last, participants were asked for their opinion on video as an assessment tool for post-ED wound bed evaluation, decision making and training.

Results: 31 physicians from 11 burn centers participated in the survey. Overall consensus (RA≥80%) in post-ED wound bed evaluation and therapy decision was achieved in 20 and 40%, respectively. Krippendorff's Alpha are given by 0.32 (95% CI: 0.15,0.49) and 0.31 (95% CI: 0.16,0.47), respectively. Subgroup analysis revealed that physicians with high experience in ED achieved significantly more consensus in post-intervention wound bed evaluation and therapy decision compared to physicians with moderate experience (60% vs. 13.3%; p=0.02 and 86.7 vs. 33.3%; p=0.04, respectively). Video analysis was considered a feasible (90.3%) and beneficial (93.5%) tool for post-intervention wound bed evaluation and therapy decision as well as useful for training purposes (100%).

Conclusion: Reliability of wound bed evaluation and therapy decision after ED depends on the experience of the rating physician. Video analysis is deemed to be a valuable tool for ED evaluation, decision making and user training.
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http://dx.doi.org/10.1093/jbcr/iraa218DOI Listing
December 2020

Management of Acute and Traumatic Wounds With Negative-Pressure Wound Therapy With Instillation and Dwell Time.

Plast Reconstr Surg 2021 01;147(1S-1):43S-53S

From the Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg; Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School; Wirth Plastic Surgery; Division of Plastic and Reconstructive Surgery, Hagey Laboratory for Pediatric Regenerative Medicine, Stanford University School of Medicine; Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University; and Department of Orthopedic Oncology and Septic Orthopedic Surgery, Orthopedic University Hospital.

Background: A promising and useful development of negative-pressure wound therapy (NPWT) is the addition of instillation and dwell time of topical wound solutions (NPWTi-d). Uses of NPWTi-d include acute and traumatic wounds, whereby wound closure may be facilitated via wound cleansing and promotion of granulation tissue formation. This systematic review summarizes publications on NPWTi-d in the treatment of acute and traumatic wounds.

Methods: A systematic review was performed analyzing articles from major clinical databases. Only clinical studies ≥10 patients reporting on the application of NPWTi-d in acute and traumatic wounds were included.

Results: One hundred ninety-two articles were retrieved, of which 10 articles met inclusion criteria. Of those, 2 were lesser-quality randomized controlled trials, comparative studies or prospective cohorts, 2 were retrospective studies, and 6 retrospective cohort studies. In total, included publications reported 109 patients with acute and traumatic wounds treated with NPWTi-d. Data from these studies indicated the potential for reduction in bacterial bioburden through wound cleansing and promotion of granulation tissue formation, thereby facilitating wound closure, reduced length of therapy and hospital time. However, for most publications, different wound causes and subsequently no isolated results for acute and traumatic wounds were reported.

Conclusion: NPWTi-d has promise to be effective in facilitating wound closure and reducing the time for wound closure. The present systematic review demonstrates a relatively low level of evidence available to objectively support this effect. To underline these positive results, large prospective, randomized controlled trials are necessary to manifest the role of NPWTi-d in the daily clinical routine for this wound category.
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http://dx.doi.org/10.1097/PRS.0000000000007610DOI Listing
January 2021
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